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Impact of COVID-19 pandemic and related isolation measures on violence against children in Egypt

Impact of COVID-19 pandemic and related isolation measures on violence against children in Egypt Background: Coronavirus disease 2019 (COVID-19) and related isolation measures have substantial adverse economic, social, and psychological consequences and expose children to increased risk of violence. The present study aimed to investigate the impact of the COVID-19 pandemic on violence against children in Egypt. Methods: An online survey, in Arabic, was disseminated during the period from 9 to 13 April 2020, to parents of children who were up to 18 years old residing in Egypt, selected using a snowball sampling technique, during the period from 25 March to 8 April during the implementation of the nationwide compulsory isolation measures against COVID-19 (25 March to 8 April 2020). The survey covered three areas: socio-demographic data, psychological impact measured using the Impact of Event Scale-Revised (IES-R), and violence against children during the past 2 weeks measured using a modified parent-report of a child abuse screening tool (ICAST-P) developed by the International Society for the Prevention of Child Abuse and Neglect. Results: Out of 1118 completed survey responses, 90.5% of children were subjected to violent discipline, 88.7% experienced psychological aggression, and 43.2% encountered severe physical punishment. Approximately 60% of respondents reported a moderate-to-severe psychological impact (IES-R scores ≥ 33), which was associated with a higher rate of violent discipline (OR: 9.3; 95% CI: 5.37–16.027; p < 0.001). Conclusions: This is the first study in Egypt to provide evidence on the association of COVID-19 pandemic, its psychological impact, and increased rates of violence against children. Effective multilevel strategies are urgently required to protect children from violence and its catastrophic consequences during the continually evolving COVID-19 pandemic. Keywords: Violence against children, Child maltreatment, COVID-19, Isolation measures, Post-traumatic stress disorder 1 Introduction has major adverse economic, social, and psychological Coronavirus disease 2019 (COVID-19) is an emerging consequences [1, 2]. and rapidly evolving major public health challenge for To limit the spread of COVID-19, countries have im- the entire global population. COVID-19 was first re- plemented variable control measures up to complete ported in December 2019 in Wuhan City (Hubei Prov- lockdown, including school closures [3]. The United Na- ince, China) and has been rapidly spreading to affect tions Educational, Scientific and Cultural Organization millions worldwide. Beyond the health crisis, COVID-19 (UNESCO) estimates that over 1.5 billion children are out of schools and childcare centers because of COVID- * Correspondence: Sehamghalib85@gmail.com 19 lockdown [4]. Consequently, families have been con- Public Health and Community Medicine Department, Sohag University, fined at home with their children. These circumstances Sohag, Egypt have had negative psychological effects and exposed the Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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Journal of the Egyptian Public Health Association (2021) 96:11 Page 2 of 10 children to an increased risk of violence with its poten- Timely knowledge and understanding of the impact of tial adverse consequences on their future life [5–8]. the COVID-19 pandemic and related isolation measures Violence against children, encompassing all forms of on violence against children are urgently required to violence against individuals under 18 years of age, is an provide updated information for the society, healthcare important public health, human right, and social con- system, and national authorities [6, 8]. The aim of the cern. Child maltreatment includes physical, psycho- present study was to identify the magnitude, pattern, logical, and sexual abuse and neglect by parents or other and risk factors of violence against children and its asso- legal caregivers. A systematic review in 2016 estimated ciation with parents’ psychological stress during the that up to 1 billion children aged 2‑17 years’ experience period of the isolation measures related to the COVID- different forms of violence every year globally [9]. Chil- 19 pandemic in Egypt. dren exposed to violence may suffer from significant life- long adverse consequences, which extend to families, 2 Methods societies, and countries [10, 11]. Under the United Na- 2.1 Study Setting, design, and participants tions Convention on the Rights of the Child, children Egypt is a developing country with approximately 100 alloverthe worldhavethe righttobesafefrom vio- million inhabitants living in an area of 1.01 million km . lence. The 2014 Egyptian Constitution and Article 1 The national trend of the COVID-19 epidemic in Egypt of the 2008 Egyptian Child Law guaranteed that right is illustrated in Fig. 1. Since the identification of the first for children [12]. In Egypt, a 2014 UNICEF study on case of COVID-19 in Egypt on February 13, 2020, the violence committed against children in Cairo, Alexan- numbers of confirmed cases, convalescent individuals, dria, and Assiut found that two-thirds of youngsters and deaths attributed to COVID-19 infection have con- within the areas covered had been subjected to phys- tinued to increase, with a significant rise since the begin- ical abuse, and 78% were victims of emotional vio- ning of April 2020. COVID-19 has affected all age lence [12]. groups from all Egyptian areas, but most deaths were Previous studies reported increased rates of psycho- among elderly people with medical comorbidities. Na- logical distress and violence against children during tional precautionary actions against COVID-19 in Egypt wide-scale health emergencies, including outbreaks of started by school closure (March 15, 2020) and extended infections, associated with school closure and social iso- to nationwide lock down (March 25, 2020) [14]. lation [13]. To date, there has been no adequate infor- This cross-sectional study was conducted between mation on violence against children during the COVID- February and April 2020. Eligible participants were 19 pandemic [6, 13]. Egyptian parents of children up to 18 years old who Fig. 1 National trend of the 2019 coronavirus disease (COVID-19) outbreak in Egypt from 13 February to 13 April 2020. The recruitment of participants took place from 9‑13 April AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 3 of 10 were residing in Egypt during the first 2 weeks of imple- [16]. First, forward translation was carried out by two in- menting the nationwide compulsory isolation measures dependent bilingual, bicultural professional translators against COVID-19 (from 25 March to 8 April 2020). We who are native Arabic speakers. A consensus version of adopted a snowball sampling technique to recruit poten- the scale was reached, which was reviewed by external tial participants. experts. Second, back translation of the first translated The sample size was calculated using the Epi Info pro- version into English was performed by another bilingual, gram developed by Centers for Disease Control and Pre- bicultural professional translator who is a native English vention (CDC) in Atlanta, Georgia (US) version7 speaker (with no access to the original English version), software, based on the following assumptions: a 68% followed by comparison with the original English source prevalence of violence against children, as reported by a to produce the second translated version. Third, face 2014 UNICEF study [12]; 95% level of confidence and validity was conducted through an online cognitive 5% precision; and 1 as design effect 1. The calculated interview with 50 potential Egyptian participants of dif- minimum sample size was 364. For proper representa- ferent educational levels to evaluate understanding, in- tion of the Egyptian community, recruitment was terpretation, and appropriateness of each item. opened for 2 weeks to maximize the sample size. A total Reliability of both questionnaires was tested using the of 1191 responses were submitted to the web-based sur- Cronbach’s alpha. The Cronbach’s alpha coefficient was vey, but missing data led to the exclusion of 73 re- 0.89 for IES-R and 0.88 for the adopted ICAST-P. sponses. Ultimately, 1118 completed questionnaires were included in the analysis. We received 42 completed re- 2.4 Survey development sponses on the first day, 384 on the second day, 435 on The survey covered three areas: socio-demographic data, the third day, 251 on the fourth day, and only 6 on the the psychological impact of COVID-19 pandemic on fifth day. The average time to complete the survey was parents, and violence against children during the study 18 min. period. Socio-demographic data included respondents’ gender, 2.2 Data collection method age, marital status, educational level, residence, employ- We used a web-based methodology for survey design, ment status, monthly income, and number of children dissemination, and data collection because the Egyptian and whether the children had chronic diseases. government imposed compulsory nationwide isolation The psychological impact of COVID-19 on survey re- measures and asked the public to minimize direct per- spondents was assessed using IES-R, which measures the sonal contact and isolate themselves at home. We pre- subjective response of adults to a certain potentially pared an anonymous electronic survey using the stressful life event. IES-R is an internationally validated, Microsoft forms (http://forms.office.com) and distrib- non-cultural specific, self-administered questionnaire, uted it to the general Egyptian population using multiple which is composed of 22 items on a five-point Likert means of communication and social media, such as scale (where 0 = not at all, and 4 = extremely) with three Facebook, Twitter, Instagram, and WhatsApp. The web- subscales: intrusion (inability to keep memories of the based survey was also sent to university students who event from returning), avoidance (an attempt to avoid were encouraged to disseminate it to other people stimuli and triggers that may bring back those memor- (friends, family members, and relatives). Potential partic- ies), and hyper arousal (a primary symptom of post- ipants for this study were invited by other study respon- traumatic stress disorder (PTSD) that occurs when a dents through an electronic link to the survey. person’s body suddenly kicks into high alert as a result Respondents completed the anonymous electronic ques- of thinking about their trauma). This instrument (IES-R) tionnaire in Arabic. Data collection occurred over 5 days is designed to capture the American Psychiatric Associ- (9–13 April 2020). ation Diagnostic and Statistical Manual of Mental Disor- ders criteria for PTSD [17]. We used a cut-off score of 2.3 Validation of the study tools ≥33 because it was reported to have good diagnostic The psychological impact of COVID-19 on survey re- power (0.88) for PTSD [18]. spondents was assessed using the Impact of Event Scale- Violence against children was assessed by the Arabic Revised (IES-R), and violence against children was parent-report version of ICAST-P [15]. The original assessed by the parent-report version of the Inter- ICAST-P asks parents about disciplinary practice and national Society for the Prevention of Child Abuse and omission of care (non-violent, moderate physical, severe Neglect (ISPCAN) child abuse screening tool (ICAST-P) physical, psychological, neglect, and sexual abuse) to- [15]. Both questionnaires were translated into Arabic ac- ward a randomly selected index child under 18 years. It cording to the standard guidelines of translation and cul- measures lifetime and past-year abusive exposure and tural adaptation of psychological and educational tests neglect (once a week or more, several times a month, AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 4 of 10 about once a month, several times a year, once or twice who were currently married (95.3%), urban residents a year, not in the past-year, or never); hence, it was not (80.6%), employed at a government agency (66.3%), well- appropriate in the present time-sensitive study. To over- educated (bachelors and postgraduate, 97.7%), and had come the long reporting time-frame, Meinck et al. previ- monthly income ≤3000 Egyptian pounds (53.1%). Most ously designed ICAST-Trial to estimate the actual of them (72.3%) had two to three children, with no number of abusive incidents in the past month (0, 1, 2, chronic medical conditions among children (93.5%) and 3, 4, 5, 6, 7, or 8+) for evaluating the effectiveness of par- no other persons living with the family in the same enting programs [19]. We adopted a similar approach household (65.6%). Most of the included index chil- through changing the response codes and reporting dren were males (60.6%), aged 2–12 years (75.7%), of time-frame to estimate the actual number of violent in- first birth order (79.7%), and in kindergarten/primary cidents (0 was assigned to not at all; 1, to once; 2, to 2–3 school (69.8%). As listed in Table 1, rates of reported times; 3, to 4–7 times; and 4, to >7 times) in the past 2 violent discipline among parents were significantly as- weeks. The neglect subscale and two items of the psy- sociated with the female gender, age 30 to 50 years, chological discipline subscale (locking out of the house urban residence, a family income ≥ 3000 Egyptian and public humiliation) were excluded because of con- pounds, less children, and presence of other individ- textual consideration (COVID-19 pandemic and related uals living with the family. Certain socio-demographic isolation measures). During the step of face validity characteristics were associated with an increased risk (interviewing nine potential study participants online), of PTSD among parents, including the female gender two items of sexual abuse were considered inappropriate and age groups 20 to <50 years with private work and unacceptable; therefore, they were also excluded. and a monthly income ≤ 3000 Egyptian pounds, as The final modified version of ICAST-P used in this presented in Table 1. study included 35 items with four subscales: non-violent Regarding the psychological impact of COVID-19, discipline (5 items), moderate physical discipline (12 the mean IES-R score of survey respondents was items), severe physical discipline (8 items), and psycho- 35.65 (±12.92). More than half of the respondents logical discipline (10 items). In addition, there were gen- (57.8%) had scores ≥ 33, indicating a moderate-to- eral questions on the index child’s age, gender, birth severe psychological impact, which is consistent with order, and educational level. PTSD (Table 2). Amongthe studiedchildren, male children, those aged <2, 2–5, and 5–8 years; those 2.5 Ethical approval with a birth order of 2–3; and those with kindergar- The study was approved by the Research Ethics Com- ten, primary, and preparatory levels of education, mittee of the Faculty of Medicine, Sohag University, and were more exposed to violence. was carried out in accordance with the principles of the As shown in Table 3 and Fig. 2, the majority of chil- 1964 Declaration of Helsinki and its 2013 revision. In- dren (90.5%) were subjected to at least one form of vio- formed consent was obtained from the respondents by lent discipline in the past 2 weeks, 88.7% experienced submitting the consent statement included in the survey. psychological aggression, and 43.2% underwent severe physical punishment. Non-violent discipline was prac- 2.6 Statistical analysis ticed by most participants. For detailed information of Survey data were analyzed using the IBM SPSS® software each subcategories of violent discipline, see Table 3. version 20 (IBM SPSS Statistics, New York, USA). De- Table 4 displayed the final model of logistic regression scriptive statistics were presented as frequencies and analysis of the psychological impact of COVID-19 on percentages for categorical variables and mean ± stand- parents and practicing different types of violent discip- ard deviation for continuous variables. Chi-squared and line against their children after adjustment of other odds ratio tests and multivariate logistic analysis were socio-demographic variables. It shows that there was a used for calculating the association between socio- strong association between psychological impact of demographic parameters, the psychological impact COVID-19 pandemic on parents and practicing violence (using an IES-R cut-off score ≥ 33), and violent discip- against their children. Children to parents with probable line. All calculations were based on alpha 5% and beta PTSD were nine times more exposed to violent discip- 80%. A p value (two-tailed) < 0.05 was considered to be line than those to parents with no/mild psychological statistically significant. impact. 3 Results 4 Discussions Descriptive statistics of the study variables are presented This is the first study in Egypt to investigate the impact in Tables 1 and 2. Participants’ ages ranged between 20 of the COVID-19 pandemic and related isolation mea- and ≥ 50 years; most respondents were mothers (88.1%), sures on violence against children. Through surveying AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 5 of 10 Table 1 Socio-demographic characteristics of survey respondents and their association with psychological impact of the pandemic on the parents and violent discipline against their children during the COVID-19 pandemic in Sohag governorate, Egypt, 2020 Parameters Parents Parents’ IES-R score ≥ OR p Parents’ violent OR p respondents 33 discipline N = 1118 (%) N = 646 (%) N = 1012. (%) Parents’ gender Male ® 133 (11.9) 60 (45.1) 108 (81.2) Female 985 (88.1) 586 (59.5) 0.56 0.002 904 (91.8) 0.387 0.00 Parents’ age (years) OR = 0.791 OR = 0.917 p = 0.009 p = 0.557 20 to <30 228 (20.4) 144 (63.5) 2.952 0.001 193 (84.6) 1.991 0.064 30 to <40 752 (67.2) 429 (57.0) 2.287 0.007 703 (93.5) 5.181 0.000 40 to <50 89 (8.0) 55 (61.8) 2.786 0.005 80 (89.9) 3.210 0.015 ≥50 ® 49 (4.4) 18 (36.7) 36 (73.5) Parents’ marital status OR = 1.23 OR = 73 × 10 p = 0.322 p = 0.997 Married 1,065 (95.3) 614 (57.7) 0.38 0.09 959 (90.0) 0.00 0.99 Divorced 35 (3.1) 18 (51.4) 0.30 0.07 35 (100) 1.00 1.00 Widow/er ® 18 (1.6) 14 (77.8) 18 (100) Parents’ residence OR = 0.804 OR = 0.467 p = 0.151 p = 0.001 Urban 901 (80.6) 530 (58.8) 1.244 0.151 829 (92.0) 2.139 0.001 Rural 217 (19.4) 116 (53.5) 183 (84.3) Parents’ employment OR = 1.17 OR = 0.995 p = 0.087 p = 0.973 No ® 285 (25.5) 157 (55.1) 256 (89.8) Government agency 741 (66.3) 425 (57.4) 1.09 0.51 674 (91.0) 1.14 0.57 Private sector 49 (4.4) 39 (79.6) 3.18 0.00 44 (89.8) 0.99 0.99 Freelancer 43 (3.8) 25 (58.1) 1.13 0.71 38 (88.4) 0.86 0.77 Parents’ highest education OR = 0.828 OR = 0.95 p = 0.080 p = 0.779 Elementary 8 (0.7) 8 (100.0) 128 × 0.999 8 (100%) 180 × 0.999 6 6 10 10 High school 18 (1.6) 9 (50.0) 0.790 0.622 13 (72.2) 0.291 0.023 Bachelors 505 (45.2) 301 (59.6) 1.165 0.214 463 (91.7) 1.232 0.325 Postgraduate ® 587 (52.5) 328 (55.9) 528 (89.9) Parents’ income (LE) OR = 0.69 OR = 2.54 p = 0.003 p < 0.001 ≤3000 594 (53.1) 368 (62) 1.441 0.003 517 (87) 0.393 0.00 ˃3000 524 (46.9) 278 (53.1) 495 (94.5) Number of children OR = 1.11 OR=2.51 p = 0.327 p < 0.001 1® 207 (18.5) 116 (56.0) 163 (78.7) 2–3 808 (72.3) 466 (57.7) 1.069 0.671 756 (93.6) 3.924 0.000 4–5 89 (8) 55 (61.8) 1.269 0.358 79 (88.8) 2.133 0.044 >5 14 (1.3) 9 (64.3) 1.412 0.548 14 (100.0) 436 × 0.999 Children with chronic disease OR = 0.743 OR = 0.687 p = 0.239 p = 0.430 Yes 73 (6.5) 47 (64.4) 1.35 0.239 68 (93.2) 1.455 0.43 No® 1045 (93.5) 599 (57.3) 944 (90.3) AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 6 of 10 Table 1 Socio-demographic characteristics of survey respondents and their association with psychological impact of the pandemic on the parents and violent discipline against their children during the COVID-19 pandemic in Sohag governorate, Egypt, 2020 (Continued) Parameters Parents Parents’ IES-R score ≥ OR p Parents’ violent OR p respondents 33 discipline N = 1118 (%) N = 646 (%) N = 1012. (%) Other individuals living with OR = 0.815 OR = 1.88 family p = 0.110 p = 0.002 Yes 385 (34.4) 235 (61.0) 1.22 0.11 334 (86.8) 0.531 0.002 No ® 733 (65.6) 411 (56.1) 678 (92.5) Total 1118 646 (57.8) 1012 (90.5) ®Reference category 1118 parents who were residing in Egypt between March impact of COVID-19, which was significantly associated 25 and April 8, 2020, we found a high rate (90.5%) of vio- with a higher rate of violent discipline. These alarming lent discipline with more than two-thirds of children ex- findings warrant a timely comprehensive strategy to sup- periencing severe physical violence. More than half of the port families and protect children from violence during respondents reported a moderate-to-severe psychological the continually evolving COVID-19 pandemic. Table 2 Socio-demographic characteristics of children exposed to different types of violent discipline during the COVID-19 pandemic in Sohag governorate, Egypt, 2020 Parameters Index Violent OR p Severe physical OR p Psychological OR p children discipline discipline discipline N = 1118. N = 1012 (%) N = 483 (%) N = 992 (%) (%) Child gender OR = 1.35 OR = 0.527 OR = 1.79 p = 0.162 p < 0.001 p = 0.005 Male 678 (60.6) 607 (59.9) 0.739 0.16 334 (69.1) 1.90 0.00 587 (59.1) 0.55 0.005 Female ® 440 (39.4) 405 (40.1) 149 (31.9) 405 (40.9) Child age (years) OR = 1.28 OR = 0.80 OR = 1.23 p < 0.001 p < 0.001 p = 0.007 <2 149 (13.3) 110 (10.8) 0.452 0.013 65 (13.4) 1.799 0.022 105 (10.5) 0.38 0.002 2–<5 286 (25.6) 271 (26.7) 2.89 0.004 148 (30.6) 2.493 0.000 271 (27.3) 2.89 0.004 5–<8 236 (21.1) 223 (22) 2.75 0.009 127 (26.2) 2.708 0.000 218 (21.9) 1.94 0.064 8–<12 324 (29) 302 (29.8) 2.20 0.021 106 (21.9) 1.130 0.594 292 (29.4) 1.46 0.235 ≥ 12 123 (11) 106 (10.4) 37 (7.6) 106 (86.2) Child birth order OR = 0.911 OR = 0.66 OR = 1.05 p = 0.561 p = 0.000 p = 0.758 1 ® 891 (79.7) 812 (80.2) 403 (83.4) 792 (79.8) 2–3 158 (14.1) 136 (13.4) 0.601 0.04 63 (13) 0.810 0.232 136 (13.7) 0.77 0.309 4–5 50 (4.5) 45 (4.4) 0.876 0.78 14 (2.8) 0.475 0.021 45 (4.5) 1.12 0.807 >5 14 (1.3) 14 (1.3) 157 × 0.99 3 (0.6) 0.000 0.998 14 (1.4) 201 × 0.999 6 6 10 10 Child education OR = 1.66 OR = 0.52 OR = 1.60 level p < 0.001 p = 0.001 p < 0.001 No ® 218 (19.5) 170 (16.7) 86 (17.8) 165 (16.6) Kindergarten 345 (30.9) 321 (31.7) 3.8 0.00 198 (11.8) 2.06 0.00 316 (31.8) 3.50 0.000 Primary school 435 (38.9) 418 (41.3) 6.9 0.00 161 (33.3) 0.90 0.55 408 (41.1) 4.85 0.000 Prep. school 99 (8.9) 82 (8.1) 1.3 0.00 34 (7) 0.80 0.39 82 (8.2) 1.54 0.157 High school 21 (1.9) 21 (2.1) 456× 0.99 4 (0.8) 0.36 0.08 21 (2.1) 518 × 0.998 6 6 10 10 Total 1118 1,012 (90.5%) 483 (43.2%) 992 (88.7%) ®Reference category AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 7 of 10 Table 3 Reported discipline practice of parents toward their Evidence demonstrates that children are at increased children during COVID-19 pandemic using adapted ICAST-P in risk of violence during times of public health emergen- Sohag governorate, Egypt, 2020 cies [8]. Several reports during the current COVID-19 Practice Respondents (%) pandemic suggested that child abuse was exacerbated (Total no. = 1118) during this time of economic uncertainty and parents Non-violent discipline 1094 (97.9) stress. In Jianli County (Hubei province, China), inci- 1. Explained 308 (28.2) dences of domestic violence reported to the police tri- pled during the lockdown in February: from 47 in 2019 2. Told to stop something 312 (28.5) to 162 in 2020 [20]. Fabbri et al., in their study that esti- 3. Time out 247 (22.5) mated the anticipated effect of COVID-19 on violent 8. Distracted 127 (11.6) discipline against 1–14-year-old children at home using 23. Took away privileges 100 (9.2) multivariable predictive regression models, reported that Moderate physical discipline 768 (68.7) in Nigeria, Mongolia, and Suriname, under a “high re- 4. Shook child (>2 years) 193 (25.2) strictions” scenario, there would be a 35–46% increase in violent discipline scores, and under a “lower restric- 6. Hit on buttocks w/object 99 (12.9) tions” scenario, there would be a 4–6% increase in vio- 7. Hit elsewhere w/object 85 (11) lent discipline scores [21]. 9. Twisted ear 84 (10.9) Results of the current study indicated that 90.5% of 10. Knuckled back of head 77 (10) the studied children were subjected to violent disci- 11. Pulled hair 83 (10.8) plines. This rate is much higher than the results of a 16. Others 0 UNICEF study conducted in 2014, wherein 68.5% of the studied children were exposed to violent disciplines, [12] 17. Painful kneel/stand 20 (2.6) despite the reporting time-frame being markedly shorter 19. Spanked on buttocks w/bare hands 33 (4.3) (2 weeks) in the present study compared to the UNICEF 20. Spanked elsewhere w/bare hands 45 (5.9) study (3 months). Our results are also higher than the 25. Pinched 26 (3.5) results of a meta-analysis of 38 reports from 96 coun- 26. Slapped face/back of head 23 (2.9) tries on past-year prevalence of violence against children Severe physical discipline 483 (43.2) that indicated that a minimum of 50% or more of chil- dren in Asia, Africa, and Northern America experienced 5. Shook child (< 2 years) 135 (28) past-year violence [9]. 15. Kicked 89 (18.4) However, a recent systematic review undertaken in 21. Choked 76 (15.7) 2019, of data of physical and emotional child maltreat- 30. Smother 58 (12) ment, sexual abuse, bullying and fighting, and violence 31. Others 0 in schools, retrieved using national population-based 32. Beat up 64 (13.3) surveys, demonstrated that physical, sexual, and emo- tional violence against adolescents is widespread in the 33. Threaten with knife or gun 61 (12.6) Arab region and that in many studies, the prevalence 35. Others 0 rates exceeded other regional or global estimates, includ- Psychological discipline 992 (88.7) ing high rates of violent discipline [22]. The higher rate 12. Threatened to abandon 134 (13.5) of violent disciplines in the current study may be ex- 13. Shouted 181 (18.2) plained by the fact that the aforementioned studies were 14. Threatened to invoke spirits 107 (10.8) conducted during usual conditions and were not related to a pandemic that necessitated lockdown. These high 18. Cursed 23 (2.3) baseline rates of violence are alarming and are expected 22. Threatened to send away 121 (12.2) to increase during the COVID-19 pandemic. Studies 24. Insulted 151 (15.3) conducted after the pandemic indicated that the rate of 27. Refused to speak 51 (5.2) violent disciplines was increased during the pandemic in 28. Withhold food 103 (10.3) many countries [23], for example, in China, Xue et al. 29. Told you wished he/she never born 100 (10.1) [23] analyzed over 1 million tweets related to family vio- lence and COVID-19 from April 12 to July 16, 2020. 34. Lock in a dark room 21 (2.1) Examining the data form the child helplines during the Violent discipline 1012 (90.5) first 6 months of 2020, Petrowski et al. demonstrated Chili pepper mouth, burn, and gave drug or alcohol that overall, the number of contacts to helplines in the The sum does not add to 100 because of multiple responses USA seemed to have drastically increased since the AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 8 of 10 Fig. 2 Distribution of studied children according to the discipline practice reported by their parents during COVID-19 pandemic, Egypt, 2020, using adapted ICAST-P beginning of the pandemic. However, they concluded during the COVID-19 pandemic [26, 27]. PTSD was pre- that the number of contacts related to violence had in- viously reported in 25.8% of respondents during the 2003 creased in some countries, whereas it had decreased in severe acute respiratory distress (SARS) outbreak in others [24]. Singapore [28]. Moreover, a study that assessed the effect The present study identified certain socio- of the COVID-19-related lockdown on Tunisian women’s demographic risk factors of violence against children mental health and gender-based violence indicated that among parents and children. Poor parental education, more than half of the participants (57.3%) reported ex- lower family income, and small number of children are tremely severe distress symptoms [29]. The higher rates of frequently reported as risk factors of violence against PTSD in our study, despite the significantly lower official children. Our results are in agreement with these studies number of cases and deaths related to COVID-19 in [9, 25]. Our results are also in accordance with the re- Egypt, may be attributed to differences in the socio- search indicating that boys and girls are at equal risks of demographic background, pronounced impact of isolation physical and psychological abuse, with a higher risk measures, and higher public fears of infection and its ad- of sexual abuse for girls [9]; that boys are more ex- verse social and economic consequences, which might be posed to violent discipline, particularly severe physical exaggerated by the mass media and the deficiency of ven- punishment; and that children under 4 years and ado- tilators and intensive care facilities. lescents are subject to a higher rate of violence that The identified risk factors of PTSD in this study are increases with age [9, 15, 22]. It is worth highlighting generally consistent with those in previous studies. Fe- that violence against children is a multifactorial prob- males and young people were reported to have a higher lem at levels, of not only individuals (parents and risk of PTSD [7, 26, 30]. In a Canadian study, partici- children) but also close relationships, community, and pants with a lower income had a significantly higher rate society [9, 22]. of PTSD related to the SARS outbreak [30]. Individuals In the present study, 57.8% of respondents had a with lower income are more likely to be affected by any moderate-to-severe psychological impact (consistent with temporary decrease in income. Workers in the private PTSD) related to the COVID-19 pandemic. These findings sector appear to be more exposed to financial loss and are in agreement with those in other studies; two studies redundancy compared to the more secure jobs in gov- in China reported PTSD in 53.8% and 7.6% of participants ernment agencies [7]. Table 4 Final model logistic regression analysis of psychological impact related to COVID-19 pandemic and violent discipline of parents against their children in Sohag governorate, Egypt, 2020 IES- R score p value OR (95% CI) <33 ≥ 33 Participants 472 (42.2) 646 (57.8) Violent discipline 382 (80.9) 630 (97.5) p <0.001 OR = 9.3 (95% CI 5.4‑16.0) Severe physical discipline 136 (28.8) 347 (53.7) p <0.001 OR = 2.9 (95% CI 2.3‑3.7) Psychological discipline 377 (79.9%) 615 (95.2%) p <0.001 OR = 5.0 (95% CI 3.3‑7.7) AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 9 of 10 The present study demonstrated a strong association 5 Conclusions between the adverse psychological impact of the This study provides an insight into the magnitude, COVID-19 pandemic in parents and rates of violence characterization, and risk factors of violence against chil- against children. Children of parents with COVID-19- dren during the COVID-19 pandemic in Egypt. The vast related PTSD were nine times more likely to be exposed majority of the studied parents (90.5%) reported prac- to violence than those of parents with no or mild psy- ticing violent discipline against their children during the chological impact. Based on previous reports of in- COVID-19 lockdown, shedding light on an alarming creased rates of PTSD with prolonged periods of situation. Poor parental education, lower family income, quarantine [7], the magnitude of violence against chil- and a large number of children were significant risk fac- dren may markedly escalate with the protracted duration tors of violence against children. Notably, more than half of the isolation measures associated with the COVID-19 of the studied parents experienced a moderate-to-severe pandemic. psychological impact (consistent with PTSD) related to Despite the challenges associated with the COVID-19 the COVID-19 pandemic, which was strongly associated pandemic and the related isolation measures, some re- with violence against children. Children of parents with searchers have indicated that this situation can be an op- COVID-19-related PTSD were nine times more likely to portunity to enhance the relationship between parents be exposed to violence than those of parents with no or and children. During lockdown times, children will mild psychological impact. These findings indicate the benefit from keeping a sound, healthy, and productive urgent need for increasing the public awareness regard- daily schedule. Having a sense of aim and routine can ing healthy parenting discipline and the best use of help children and adults avoid negative feelings [5, 6, 8]. childhood time at home, as well as setting up a secure The findings of this study will contribute to the ongoing and easy system for parental counseling. Providing the efforts of protecting children from violence during the parents with psychological support during this pandemic rapidly expanding COVID-19 pandemic in Egypt and and training of healthcare professionals to regular the world. screening for child abuse and neglect are highly recom- mended particularly those with poor socioeconomic sta- 4.1 Limitations tus, to overcome the burden of the COVID-19 pandemic The present study has some limitations. First, we and isolation measures. used a snowball sampling strategy because of the lim- Abbreviations ited resources and time-sensitivity of the COVID-19 CDC: Centers for Disease Control and Prevention; COVID-19: Coronavirus pandemic. This sampling strategy does not rely on disease 2019; ICAST-P: Child Abuse Screening Tool-Parents; IES-R: Impact of Event Scale-Revised; ISPCAN: International Society for the Prevention of Child random selection; consequently, the study population Abuse and Neglect; PTSD: Post-traumatic stress disorder; SARS: Severe acute does not mirror the actual characteristics of the gen- respiratory distress syndrome; UNESCO: United Nations Educational, Scientific eral population. Second, the use of a web-based and Cultural Organization; UNICEF: The United Nations Children’s Fund method for data collection might have restricted study Acknowledgements participation to individuals with certain education and Not applicable technology skills. This limits the generalizability of study findings, particularly among the less educated Authors’ contributions EA prepared the online questionnaire, participated in its distribution and population. Third, for ethical reasons and age limits, wrote the manuscript. SA contributed to the questionnaire distribution, violence against children was evaluated based on par- statistical analysis of the data, and review of the final manuscript. RA ents’ reports only; children’s reports were not studied. contributed to reanalysis of the data and rewriting the manuscript based on the reviewers’ comments. All authors have read and approved the Fourth, it would have been ideal to carry out a manuscript. follow-up study on the same study population to pro- vide stronger evidence, investigate the effectiveness of Funding intervention programs, and study the potential psy- No fund received. chosocial impact of violence on the children. How- Availability of data and materials ever, this is not applicable given the ethical mandate All data are available on demand from the corresponding author. of anonymity and confidentiality. Fifth, the data were collected after only 1 month of the lockdown, and Declarations the expectation is that the rate of violence will escal- Ethics approval and consent to participate ate with prolonged lockdown and school closure. Fi- This study was approved by the institutional Research Ethics Committee, nally, the pattern of violence described cannot be Faculty of Medicine, Sohag University, on 1 April 2020 and was carried out in accordance with the principles of the 1964 Declaration of Helsinki and its attributed to COVID-19 in view of the absence of in- 2013 revision. Committee reference No.: not available. Informed consent of formation regarding the child disciplinary pattern participants was obtained from the respondents by submitting the consent prior to the pandemic. statement included in the online survey. AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 10 of 10 Consent for publication against children. 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Fabbri C, Bhatia A, Petzold M, Jugder M, Guedes A, Cappa C, et al. Modelling the effect of the COVID-19 pandemic on violent discipline http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Impact of COVID-19 pandemic and related isolation measures on violence against children in Egypt

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2090-262X
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10.1186/s42506-021-00071-4
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Abstract

Background: Coronavirus disease 2019 (COVID-19) and related isolation measures have substantial adverse economic, social, and psychological consequences and expose children to increased risk of violence. The present study aimed to investigate the impact of the COVID-19 pandemic on violence against children in Egypt. Methods: An online survey, in Arabic, was disseminated during the period from 9 to 13 April 2020, to parents of children who were up to 18 years old residing in Egypt, selected using a snowball sampling technique, during the period from 25 March to 8 April during the implementation of the nationwide compulsory isolation measures against COVID-19 (25 March to 8 April 2020). The survey covered three areas: socio-demographic data, psychological impact measured using the Impact of Event Scale-Revised (IES-R), and violence against children during the past 2 weeks measured using a modified parent-report of a child abuse screening tool (ICAST-P) developed by the International Society for the Prevention of Child Abuse and Neglect. Results: Out of 1118 completed survey responses, 90.5% of children were subjected to violent discipline, 88.7% experienced psychological aggression, and 43.2% encountered severe physical punishment. Approximately 60% of respondents reported a moderate-to-severe psychological impact (IES-R scores ≥ 33), which was associated with a higher rate of violent discipline (OR: 9.3; 95% CI: 5.37–16.027; p < 0.001). Conclusions: This is the first study in Egypt to provide evidence on the association of COVID-19 pandemic, its psychological impact, and increased rates of violence against children. Effective multilevel strategies are urgently required to protect children from violence and its catastrophic consequences during the continually evolving COVID-19 pandemic. Keywords: Violence against children, Child maltreatment, COVID-19, Isolation measures, Post-traumatic stress disorder 1 Introduction has major adverse economic, social, and psychological Coronavirus disease 2019 (COVID-19) is an emerging consequences [1, 2]. and rapidly evolving major public health challenge for To limit the spread of COVID-19, countries have im- the entire global population. COVID-19 was first re- plemented variable control measures up to complete ported in December 2019 in Wuhan City (Hubei Prov- lockdown, including school closures [3]. The United Na- ince, China) and has been rapidly spreading to affect tions Educational, Scientific and Cultural Organization millions worldwide. Beyond the health crisis, COVID-19 (UNESCO) estimates that over 1.5 billion children are out of schools and childcare centers because of COVID- * Correspondence: Sehamghalib85@gmail.com 19 lockdown [4]. Consequently, families have been con- Public Health and Community Medicine Department, Sohag University, fined at home with their children. These circumstances Sohag, Egypt have had negative psychological effects and exposed the Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 2 of 10 children to an increased risk of violence with its poten- Timely knowledge and understanding of the impact of tial adverse consequences on their future life [5–8]. the COVID-19 pandemic and related isolation measures Violence against children, encompassing all forms of on violence against children are urgently required to violence against individuals under 18 years of age, is an provide updated information for the society, healthcare important public health, human right, and social con- system, and national authorities [6, 8]. The aim of the cern. Child maltreatment includes physical, psycho- present study was to identify the magnitude, pattern, logical, and sexual abuse and neglect by parents or other and risk factors of violence against children and its asso- legal caregivers. A systematic review in 2016 estimated ciation with parents’ psychological stress during the that up to 1 billion children aged 2‑17 years’ experience period of the isolation measures related to the COVID- different forms of violence every year globally [9]. Chil- 19 pandemic in Egypt. dren exposed to violence may suffer from significant life- long adverse consequences, which extend to families, 2 Methods societies, and countries [10, 11]. Under the United Na- 2.1 Study Setting, design, and participants tions Convention on the Rights of the Child, children Egypt is a developing country with approximately 100 alloverthe worldhavethe righttobesafefrom vio- million inhabitants living in an area of 1.01 million km . lence. The 2014 Egyptian Constitution and Article 1 The national trend of the COVID-19 epidemic in Egypt of the 2008 Egyptian Child Law guaranteed that right is illustrated in Fig. 1. Since the identification of the first for children [12]. In Egypt, a 2014 UNICEF study on case of COVID-19 in Egypt on February 13, 2020, the violence committed against children in Cairo, Alexan- numbers of confirmed cases, convalescent individuals, dria, and Assiut found that two-thirds of youngsters and deaths attributed to COVID-19 infection have con- within the areas covered had been subjected to phys- tinued to increase, with a significant rise since the begin- ical abuse, and 78% were victims of emotional vio- ning of April 2020. COVID-19 has affected all age lence [12]. groups from all Egyptian areas, but most deaths were Previous studies reported increased rates of psycho- among elderly people with medical comorbidities. Na- logical distress and violence against children during tional precautionary actions against COVID-19 in Egypt wide-scale health emergencies, including outbreaks of started by school closure (March 15, 2020) and extended infections, associated with school closure and social iso- to nationwide lock down (March 25, 2020) [14]. lation [13]. To date, there has been no adequate infor- This cross-sectional study was conducted between mation on violence against children during the COVID- February and April 2020. Eligible participants were 19 pandemic [6, 13]. Egyptian parents of children up to 18 years old who Fig. 1 National trend of the 2019 coronavirus disease (COVID-19) outbreak in Egypt from 13 February to 13 April 2020. The recruitment of participants took place from 9‑13 April AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 3 of 10 were residing in Egypt during the first 2 weeks of imple- [16]. First, forward translation was carried out by two in- menting the nationwide compulsory isolation measures dependent bilingual, bicultural professional translators against COVID-19 (from 25 March to 8 April 2020). We who are native Arabic speakers. A consensus version of adopted a snowball sampling technique to recruit poten- the scale was reached, which was reviewed by external tial participants. experts. Second, back translation of the first translated The sample size was calculated using the Epi Info pro- version into English was performed by another bilingual, gram developed by Centers for Disease Control and Pre- bicultural professional translator who is a native English vention (CDC) in Atlanta, Georgia (US) version7 speaker (with no access to the original English version), software, based on the following assumptions: a 68% followed by comparison with the original English source prevalence of violence against children, as reported by a to produce the second translated version. Third, face 2014 UNICEF study [12]; 95% level of confidence and validity was conducted through an online cognitive 5% precision; and 1 as design effect 1. The calculated interview with 50 potential Egyptian participants of dif- minimum sample size was 364. For proper representa- ferent educational levels to evaluate understanding, in- tion of the Egyptian community, recruitment was terpretation, and appropriateness of each item. opened for 2 weeks to maximize the sample size. A total Reliability of both questionnaires was tested using the of 1191 responses were submitted to the web-based sur- Cronbach’s alpha. The Cronbach’s alpha coefficient was vey, but missing data led to the exclusion of 73 re- 0.89 for IES-R and 0.88 for the adopted ICAST-P. sponses. Ultimately, 1118 completed questionnaires were included in the analysis. We received 42 completed re- 2.4 Survey development sponses on the first day, 384 on the second day, 435 on The survey covered three areas: socio-demographic data, the third day, 251 on the fourth day, and only 6 on the the psychological impact of COVID-19 pandemic on fifth day. The average time to complete the survey was parents, and violence against children during the study 18 min. period. Socio-demographic data included respondents’ gender, 2.2 Data collection method age, marital status, educational level, residence, employ- We used a web-based methodology for survey design, ment status, monthly income, and number of children dissemination, and data collection because the Egyptian and whether the children had chronic diseases. government imposed compulsory nationwide isolation The psychological impact of COVID-19 on survey re- measures and asked the public to minimize direct per- spondents was assessed using IES-R, which measures the sonal contact and isolate themselves at home. We pre- subjective response of adults to a certain potentially pared an anonymous electronic survey using the stressful life event. IES-R is an internationally validated, Microsoft forms (http://forms.office.com) and distrib- non-cultural specific, self-administered questionnaire, uted it to the general Egyptian population using multiple which is composed of 22 items on a five-point Likert means of communication and social media, such as scale (where 0 = not at all, and 4 = extremely) with three Facebook, Twitter, Instagram, and WhatsApp. The web- subscales: intrusion (inability to keep memories of the based survey was also sent to university students who event from returning), avoidance (an attempt to avoid were encouraged to disseminate it to other people stimuli and triggers that may bring back those memor- (friends, family members, and relatives). Potential partic- ies), and hyper arousal (a primary symptom of post- ipants for this study were invited by other study respon- traumatic stress disorder (PTSD) that occurs when a dents through an electronic link to the survey. person’s body suddenly kicks into high alert as a result Respondents completed the anonymous electronic ques- of thinking about their trauma). This instrument (IES-R) tionnaire in Arabic. Data collection occurred over 5 days is designed to capture the American Psychiatric Associ- (9–13 April 2020). ation Diagnostic and Statistical Manual of Mental Disor- ders criteria for PTSD [17]. We used a cut-off score of 2.3 Validation of the study tools ≥33 because it was reported to have good diagnostic The psychological impact of COVID-19 on survey re- power (0.88) for PTSD [18]. spondents was assessed using the Impact of Event Scale- Violence against children was assessed by the Arabic Revised (IES-R), and violence against children was parent-report version of ICAST-P [15]. The original assessed by the parent-report version of the Inter- ICAST-P asks parents about disciplinary practice and national Society for the Prevention of Child Abuse and omission of care (non-violent, moderate physical, severe Neglect (ISPCAN) child abuse screening tool (ICAST-P) physical, psychological, neglect, and sexual abuse) to- [15]. Both questionnaires were translated into Arabic ac- ward a randomly selected index child under 18 years. It cording to the standard guidelines of translation and cul- measures lifetime and past-year abusive exposure and tural adaptation of psychological and educational tests neglect (once a week or more, several times a month, AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 4 of 10 about once a month, several times a year, once or twice who were currently married (95.3%), urban residents a year, not in the past-year, or never); hence, it was not (80.6%), employed at a government agency (66.3%), well- appropriate in the present time-sensitive study. To over- educated (bachelors and postgraduate, 97.7%), and had come the long reporting time-frame, Meinck et al. previ- monthly income ≤3000 Egyptian pounds (53.1%). Most ously designed ICAST-Trial to estimate the actual of them (72.3%) had two to three children, with no number of abusive incidents in the past month (0, 1, 2, chronic medical conditions among children (93.5%) and 3, 4, 5, 6, 7, or 8+) for evaluating the effectiveness of par- no other persons living with the family in the same enting programs [19]. We adopted a similar approach household (65.6%). Most of the included index chil- through changing the response codes and reporting dren were males (60.6%), aged 2–12 years (75.7%), of time-frame to estimate the actual number of violent in- first birth order (79.7%), and in kindergarten/primary cidents (0 was assigned to not at all; 1, to once; 2, to 2–3 school (69.8%). As listed in Table 1, rates of reported times; 3, to 4–7 times; and 4, to >7 times) in the past 2 violent discipline among parents were significantly as- weeks. The neglect subscale and two items of the psy- sociated with the female gender, age 30 to 50 years, chological discipline subscale (locking out of the house urban residence, a family income ≥ 3000 Egyptian and public humiliation) were excluded because of con- pounds, less children, and presence of other individ- textual consideration (COVID-19 pandemic and related uals living with the family. Certain socio-demographic isolation measures). During the step of face validity characteristics were associated with an increased risk (interviewing nine potential study participants online), of PTSD among parents, including the female gender two items of sexual abuse were considered inappropriate and age groups 20 to <50 years with private work and unacceptable; therefore, they were also excluded. and a monthly income ≤ 3000 Egyptian pounds, as The final modified version of ICAST-P used in this presented in Table 1. study included 35 items with four subscales: non-violent Regarding the psychological impact of COVID-19, discipline (5 items), moderate physical discipline (12 the mean IES-R score of survey respondents was items), severe physical discipline (8 items), and psycho- 35.65 (±12.92). More than half of the respondents logical discipline (10 items). In addition, there were gen- (57.8%) had scores ≥ 33, indicating a moderate-to- eral questions on the index child’s age, gender, birth severe psychological impact, which is consistent with order, and educational level. PTSD (Table 2). Amongthe studiedchildren, male children, those aged <2, 2–5, and 5–8 years; those 2.5 Ethical approval with a birth order of 2–3; and those with kindergar- The study was approved by the Research Ethics Com- ten, primary, and preparatory levels of education, mittee of the Faculty of Medicine, Sohag University, and were more exposed to violence. was carried out in accordance with the principles of the As shown in Table 3 and Fig. 2, the majority of chil- 1964 Declaration of Helsinki and its 2013 revision. In- dren (90.5%) were subjected to at least one form of vio- formed consent was obtained from the respondents by lent discipline in the past 2 weeks, 88.7% experienced submitting the consent statement included in the survey. psychological aggression, and 43.2% underwent severe physical punishment. Non-violent discipline was prac- 2.6 Statistical analysis ticed by most participants. For detailed information of Survey data were analyzed using the IBM SPSS® software each subcategories of violent discipline, see Table 3. version 20 (IBM SPSS Statistics, New York, USA). De- Table 4 displayed the final model of logistic regression scriptive statistics were presented as frequencies and analysis of the psychological impact of COVID-19 on percentages for categorical variables and mean ± stand- parents and practicing different types of violent discip- ard deviation for continuous variables. Chi-squared and line against their children after adjustment of other odds ratio tests and multivariate logistic analysis were socio-demographic variables. It shows that there was a used for calculating the association between socio- strong association between psychological impact of demographic parameters, the psychological impact COVID-19 pandemic on parents and practicing violence (using an IES-R cut-off score ≥ 33), and violent discip- against their children. Children to parents with probable line. All calculations were based on alpha 5% and beta PTSD were nine times more exposed to violent discip- 80%. A p value (two-tailed) < 0.05 was considered to be line than those to parents with no/mild psychological statistically significant. impact. 3 Results 4 Discussions Descriptive statistics of the study variables are presented This is the first study in Egypt to investigate the impact in Tables 1 and 2. Participants’ ages ranged between 20 of the COVID-19 pandemic and related isolation mea- and ≥ 50 years; most respondents were mothers (88.1%), sures on violence against children. Through surveying AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 5 of 10 Table 1 Socio-demographic characteristics of survey respondents and their association with psychological impact of the pandemic on the parents and violent discipline against their children during the COVID-19 pandemic in Sohag governorate, Egypt, 2020 Parameters Parents Parents’ IES-R score ≥ OR p Parents’ violent OR p respondents 33 discipline N = 1118 (%) N = 646 (%) N = 1012. (%) Parents’ gender Male ® 133 (11.9) 60 (45.1) 108 (81.2) Female 985 (88.1) 586 (59.5) 0.56 0.002 904 (91.8) 0.387 0.00 Parents’ age (years) OR = 0.791 OR = 0.917 p = 0.009 p = 0.557 20 to <30 228 (20.4) 144 (63.5) 2.952 0.001 193 (84.6) 1.991 0.064 30 to <40 752 (67.2) 429 (57.0) 2.287 0.007 703 (93.5) 5.181 0.000 40 to <50 89 (8.0) 55 (61.8) 2.786 0.005 80 (89.9) 3.210 0.015 ≥50 ® 49 (4.4) 18 (36.7) 36 (73.5) Parents’ marital status OR = 1.23 OR = 73 × 10 p = 0.322 p = 0.997 Married 1,065 (95.3) 614 (57.7) 0.38 0.09 959 (90.0) 0.00 0.99 Divorced 35 (3.1) 18 (51.4) 0.30 0.07 35 (100) 1.00 1.00 Widow/er ® 18 (1.6) 14 (77.8) 18 (100) Parents’ residence OR = 0.804 OR = 0.467 p = 0.151 p = 0.001 Urban 901 (80.6) 530 (58.8) 1.244 0.151 829 (92.0) 2.139 0.001 Rural 217 (19.4) 116 (53.5) 183 (84.3) Parents’ employment OR = 1.17 OR = 0.995 p = 0.087 p = 0.973 No ® 285 (25.5) 157 (55.1) 256 (89.8) Government agency 741 (66.3) 425 (57.4) 1.09 0.51 674 (91.0) 1.14 0.57 Private sector 49 (4.4) 39 (79.6) 3.18 0.00 44 (89.8) 0.99 0.99 Freelancer 43 (3.8) 25 (58.1) 1.13 0.71 38 (88.4) 0.86 0.77 Parents’ highest education OR = 0.828 OR = 0.95 p = 0.080 p = 0.779 Elementary 8 (0.7) 8 (100.0) 128 × 0.999 8 (100%) 180 × 0.999 6 6 10 10 High school 18 (1.6) 9 (50.0) 0.790 0.622 13 (72.2) 0.291 0.023 Bachelors 505 (45.2) 301 (59.6) 1.165 0.214 463 (91.7) 1.232 0.325 Postgraduate ® 587 (52.5) 328 (55.9) 528 (89.9) Parents’ income (LE) OR = 0.69 OR = 2.54 p = 0.003 p < 0.001 ≤3000 594 (53.1) 368 (62) 1.441 0.003 517 (87) 0.393 0.00 ˃3000 524 (46.9) 278 (53.1) 495 (94.5) Number of children OR = 1.11 OR=2.51 p = 0.327 p < 0.001 1® 207 (18.5) 116 (56.0) 163 (78.7) 2–3 808 (72.3) 466 (57.7) 1.069 0.671 756 (93.6) 3.924 0.000 4–5 89 (8) 55 (61.8) 1.269 0.358 79 (88.8) 2.133 0.044 >5 14 (1.3) 9 (64.3) 1.412 0.548 14 (100.0) 436 × 0.999 Children with chronic disease OR = 0.743 OR = 0.687 p = 0.239 p = 0.430 Yes 73 (6.5) 47 (64.4) 1.35 0.239 68 (93.2) 1.455 0.43 No® 1045 (93.5) 599 (57.3) 944 (90.3) AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 6 of 10 Table 1 Socio-demographic characteristics of survey respondents and their association with psychological impact of the pandemic on the parents and violent discipline against their children during the COVID-19 pandemic in Sohag governorate, Egypt, 2020 (Continued) Parameters Parents Parents’ IES-R score ≥ OR p Parents’ violent OR p respondents 33 discipline N = 1118 (%) N = 646 (%) N = 1012. (%) Other individuals living with OR = 0.815 OR = 1.88 family p = 0.110 p = 0.002 Yes 385 (34.4) 235 (61.0) 1.22 0.11 334 (86.8) 0.531 0.002 No ® 733 (65.6) 411 (56.1) 678 (92.5) Total 1118 646 (57.8) 1012 (90.5) ®Reference category 1118 parents who were residing in Egypt between March impact of COVID-19, which was significantly associated 25 and April 8, 2020, we found a high rate (90.5%) of vio- with a higher rate of violent discipline. These alarming lent discipline with more than two-thirds of children ex- findings warrant a timely comprehensive strategy to sup- periencing severe physical violence. More than half of the port families and protect children from violence during respondents reported a moderate-to-severe psychological the continually evolving COVID-19 pandemic. Table 2 Socio-demographic characteristics of children exposed to different types of violent discipline during the COVID-19 pandemic in Sohag governorate, Egypt, 2020 Parameters Index Violent OR p Severe physical OR p Psychological OR p children discipline discipline discipline N = 1118. N = 1012 (%) N = 483 (%) N = 992 (%) (%) Child gender OR = 1.35 OR = 0.527 OR = 1.79 p = 0.162 p < 0.001 p = 0.005 Male 678 (60.6) 607 (59.9) 0.739 0.16 334 (69.1) 1.90 0.00 587 (59.1) 0.55 0.005 Female ® 440 (39.4) 405 (40.1) 149 (31.9) 405 (40.9) Child age (years) OR = 1.28 OR = 0.80 OR = 1.23 p < 0.001 p < 0.001 p = 0.007 <2 149 (13.3) 110 (10.8) 0.452 0.013 65 (13.4) 1.799 0.022 105 (10.5) 0.38 0.002 2–<5 286 (25.6) 271 (26.7) 2.89 0.004 148 (30.6) 2.493 0.000 271 (27.3) 2.89 0.004 5–<8 236 (21.1) 223 (22) 2.75 0.009 127 (26.2) 2.708 0.000 218 (21.9) 1.94 0.064 8–<12 324 (29) 302 (29.8) 2.20 0.021 106 (21.9) 1.130 0.594 292 (29.4) 1.46 0.235 ≥ 12 123 (11) 106 (10.4) 37 (7.6) 106 (86.2) Child birth order OR = 0.911 OR = 0.66 OR = 1.05 p = 0.561 p = 0.000 p = 0.758 1 ® 891 (79.7) 812 (80.2) 403 (83.4) 792 (79.8) 2–3 158 (14.1) 136 (13.4) 0.601 0.04 63 (13) 0.810 0.232 136 (13.7) 0.77 0.309 4–5 50 (4.5) 45 (4.4) 0.876 0.78 14 (2.8) 0.475 0.021 45 (4.5) 1.12 0.807 >5 14 (1.3) 14 (1.3) 157 × 0.99 3 (0.6) 0.000 0.998 14 (1.4) 201 × 0.999 6 6 10 10 Child education OR = 1.66 OR = 0.52 OR = 1.60 level p < 0.001 p = 0.001 p < 0.001 No ® 218 (19.5) 170 (16.7) 86 (17.8) 165 (16.6) Kindergarten 345 (30.9) 321 (31.7) 3.8 0.00 198 (11.8) 2.06 0.00 316 (31.8) 3.50 0.000 Primary school 435 (38.9) 418 (41.3) 6.9 0.00 161 (33.3) 0.90 0.55 408 (41.1) 4.85 0.000 Prep. school 99 (8.9) 82 (8.1) 1.3 0.00 34 (7) 0.80 0.39 82 (8.2) 1.54 0.157 High school 21 (1.9) 21 (2.1) 456× 0.99 4 (0.8) 0.36 0.08 21 (2.1) 518 × 0.998 6 6 10 10 Total 1118 1,012 (90.5%) 483 (43.2%) 992 (88.7%) ®Reference category AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 7 of 10 Table 3 Reported discipline practice of parents toward their Evidence demonstrates that children are at increased children during COVID-19 pandemic using adapted ICAST-P in risk of violence during times of public health emergen- Sohag governorate, Egypt, 2020 cies [8]. Several reports during the current COVID-19 Practice Respondents (%) pandemic suggested that child abuse was exacerbated (Total no. = 1118) during this time of economic uncertainty and parents Non-violent discipline 1094 (97.9) stress. In Jianli County (Hubei province, China), inci- 1. Explained 308 (28.2) dences of domestic violence reported to the police tri- pled during the lockdown in February: from 47 in 2019 2. Told to stop something 312 (28.5) to 162 in 2020 [20]. Fabbri et al., in their study that esti- 3. Time out 247 (22.5) mated the anticipated effect of COVID-19 on violent 8. Distracted 127 (11.6) discipline against 1–14-year-old children at home using 23. Took away privileges 100 (9.2) multivariable predictive regression models, reported that Moderate physical discipline 768 (68.7) in Nigeria, Mongolia, and Suriname, under a “high re- 4. Shook child (>2 years) 193 (25.2) strictions” scenario, there would be a 35–46% increase in violent discipline scores, and under a “lower restric- 6. Hit on buttocks w/object 99 (12.9) tions” scenario, there would be a 4–6% increase in vio- 7. Hit elsewhere w/object 85 (11) lent discipline scores [21]. 9. Twisted ear 84 (10.9) Results of the current study indicated that 90.5% of 10. Knuckled back of head 77 (10) the studied children were subjected to violent disci- 11. Pulled hair 83 (10.8) plines. This rate is much higher than the results of a 16. Others 0 UNICEF study conducted in 2014, wherein 68.5% of the studied children were exposed to violent disciplines, [12] 17. Painful kneel/stand 20 (2.6) despite the reporting time-frame being markedly shorter 19. Spanked on buttocks w/bare hands 33 (4.3) (2 weeks) in the present study compared to the UNICEF 20. Spanked elsewhere w/bare hands 45 (5.9) study (3 months). Our results are also higher than the 25. Pinched 26 (3.5) results of a meta-analysis of 38 reports from 96 coun- 26. Slapped face/back of head 23 (2.9) tries on past-year prevalence of violence against children Severe physical discipline 483 (43.2) that indicated that a minimum of 50% or more of chil- dren in Asia, Africa, and Northern America experienced 5. Shook child (< 2 years) 135 (28) past-year violence [9]. 15. Kicked 89 (18.4) However, a recent systematic review undertaken in 21. Choked 76 (15.7) 2019, of data of physical and emotional child maltreat- 30. Smother 58 (12) ment, sexual abuse, bullying and fighting, and violence 31. Others 0 in schools, retrieved using national population-based 32. Beat up 64 (13.3) surveys, demonstrated that physical, sexual, and emo- tional violence against adolescents is widespread in the 33. Threaten with knife or gun 61 (12.6) Arab region and that in many studies, the prevalence 35. Others 0 rates exceeded other regional or global estimates, includ- Psychological discipline 992 (88.7) ing high rates of violent discipline [22]. The higher rate 12. Threatened to abandon 134 (13.5) of violent disciplines in the current study may be ex- 13. Shouted 181 (18.2) plained by the fact that the aforementioned studies were 14. Threatened to invoke spirits 107 (10.8) conducted during usual conditions and were not related to a pandemic that necessitated lockdown. These high 18. Cursed 23 (2.3) baseline rates of violence are alarming and are expected 22. Threatened to send away 121 (12.2) to increase during the COVID-19 pandemic. Studies 24. Insulted 151 (15.3) conducted after the pandemic indicated that the rate of 27. Refused to speak 51 (5.2) violent disciplines was increased during the pandemic in 28. Withhold food 103 (10.3) many countries [23], for example, in China, Xue et al. 29. Told you wished he/she never born 100 (10.1) [23] analyzed over 1 million tweets related to family vio- lence and COVID-19 from April 12 to July 16, 2020. 34. Lock in a dark room 21 (2.1) Examining the data form the child helplines during the Violent discipline 1012 (90.5) first 6 months of 2020, Petrowski et al. demonstrated Chili pepper mouth, burn, and gave drug or alcohol that overall, the number of contacts to helplines in the The sum does not add to 100 because of multiple responses USA seemed to have drastically increased since the AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 8 of 10 Fig. 2 Distribution of studied children according to the discipline practice reported by their parents during COVID-19 pandemic, Egypt, 2020, using adapted ICAST-P beginning of the pandemic. However, they concluded during the COVID-19 pandemic [26, 27]. PTSD was pre- that the number of contacts related to violence had in- viously reported in 25.8% of respondents during the 2003 creased in some countries, whereas it had decreased in severe acute respiratory distress (SARS) outbreak in others [24]. Singapore [28]. Moreover, a study that assessed the effect The present study identified certain socio- of the COVID-19-related lockdown on Tunisian women’s demographic risk factors of violence against children mental health and gender-based violence indicated that among parents and children. Poor parental education, more than half of the participants (57.3%) reported ex- lower family income, and small number of children are tremely severe distress symptoms [29]. The higher rates of frequently reported as risk factors of violence against PTSD in our study, despite the significantly lower official children. Our results are in agreement with these studies number of cases and deaths related to COVID-19 in [9, 25]. Our results are also in accordance with the re- Egypt, may be attributed to differences in the socio- search indicating that boys and girls are at equal risks of demographic background, pronounced impact of isolation physical and psychological abuse, with a higher risk measures, and higher public fears of infection and its ad- of sexual abuse for girls [9]; that boys are more ex- verse social and economic consequences, which might be posed to violent discipline, particularly severe physical exaggerated by the mass media and the deficiency of ven- punishment; and that children under 4 years and ado- tilators and intensive care facilities. lescents are subject to a higher rate of violence that The identified risk factors of PTSD in this study are increases with age [9, 15, 22]. It is worth highlighting generally consistent with those in previous studies. Fe- that violence against children is a multifactorial prob- males and young people were reported to have a higher lem at levels, of not only individuals (parents and risk of PTSD [7, 26, 30]. In a Canadian study, partici- children) but also close relationships, community, and pants with a lower income had a significantly higher rate society [9, 22]. of PTSD related to the SARS outbreak [30]. Individuals In the present study, 57.8% of respondents had a with lower income are more likely to be affected by any moderate-to-severe psychological impact (consistent with temporary decrease in income. Workers in the private PTSD) related to the COVID-19 pandemic. These findings sector appear to be more exposed to financial loss and are in agreement with those in other studies; two studies redundancy compared to the more secure jobs in gov- in China reported PTSD in 53.8% and 7.6% of participants ernment agencies [7]. Table 4 Final model logistic regression analysis of psychological impact related to COVID-19 pandemic and violent discipline of parents against their children in Sohag governorate, Egypt, 2020 IES- R score p value OR (95% CI) <33 ≥ 33 Participants 472 (42.2) 646 (57.8) Violent discipline 382 (80.9) 630 (97.5) p <0.001 OR = 9.3 (95% CI 5.4‑16.0) Severe physical discipline 136 (28.8) 347 (53.7) p <0.001 OR = 2.9 (95% CI 2.3‑3.7) Psychological discipline 377 (79.9%) 615 (95.2%) p <0.001 OR = 5.0 (95% CI 3.3‑7.7) AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 9 of 10 The present study demonstrated a strong association 5 Conclusions between the adverse psychological impact of the This study provides an insight into the magnitude, COVID-19 pandemic in parents and rates of violence characterization, and risk factors of violence against chil- against children. Children of parents with COVID-19- dren during the COVID-19 pandemic in Egypt. The vast related PTSD were nine times more likely to be exposed majority of the studied parents (90.5%) reported prac- to violence than those of parents with no or mild psy- ticing violent discipline against their children during the chological impact. Based on previous reports of in- COVID-19 lockdown, shedding light on an alarming creased rates of PTSD with prolonged periods of situation. Poor parental education, lower family income, quarantine [7], the magnitude of violence against chil- and a large number of children were significant risk fac- dren may markedly escalate with the protracted duration tors of violence against children. Notably, more than half of the isolation measures associated with the COVID-19 of the studied parents experienced a moderate-to-severe pandemic. psychological impact (consistent with PTSD) related to Despite the challenges associated with the COVID-19 the COVID-19 pandemic, which was strongly associated pandemic and the related isolation measures, some re- with violence against children. Children of parents with searchers have indicated that this situation can be an op- COVID-19-related PTSD were nine times more likely to portunity to enhance the relationship between parents be exposed to violence than those of parents with no or and children. During lockdown times, children will mild psychological impact. These findings indicate the benefit from keeping a sound, healthy, and productive urgent need for increasing the public awareness regard- daily schedule. Having a sense of aim and routine can ing healthy parenting discipline and the best use of help children and adults avoid negative feelings [5, 6, 8]. childhood time at home, as well as setting up a secure The findings of this study will contribute to the ongoing and easy system for parental counseling. Providing the efforts of protecting children from violence during the parents with psychological support during this pandemic rapidly expanding COVID-19 pandemic in Egypt and and training of healthcare professionals to regular the world. screening for child abuse and neglect are highly recom- mended particularly those with poor socioeconomic sta- 4.1 Limitations tus, to overcome the burden of the COVID-19 pandemic The present study has some limitations. First, we and isolation measures. used a snowball sampling strategy because of the lim- Abbreviations ited resources and time-sensitivity of the COVID-19 CDC: Centers for Disease Control and Prevention; COVID-19: Coronavirus pandemic. This sampling strategy does not rely on disease 2019; ICAST-P: Child Abuse Screening Tool-Parents; IES-R: Impact of Event Scale-Revised; ISPCAN: International Society for the Prevention of Child random selection; consequently, the study population Abuse and Neglect; PTSD: Post-traumatic stress disorder; SARS: Severe acute does not mirror the actual characteristics of the gen- respiratory distress syndrome; UNESCO: United Nations Educational, Scientific eral population. Second, the use of a web-based and Cultural Organization; UNICEF: The United Nations Children’s Fund method for data collection might have restricted study Acknowledgements participation to individuals with certain education and Not applicable technology skills. This limits the generalizability of study findings, particularly among the less educated Authors’ contributions EA prepared the online questionnaire, participated in its distribution and population. Third, for ethical reasons and age limits, wrote the manuscript. SA contributed to the questionnaire distribution, violence against children was evaluated based on par- statistical analysis of the data, and review of the final manuscript. RA ents’ reports only; children’s reports were not studied. contributed to reanalysis of the data and rewriting the manuscript based on the reviewers’ comments. All authors have read and approved the Fourth, it would have been ideal to carry out a manuscript. follow-up study on the same study population to pro- vide stronger evidence, investigate the effectiveness of Funding intervention programs, and study the potential psy- No fund received. chosocial impact of violence on the children. How- Availability of data and materials ever, this is not applicable given the ethical mandate All data are available on demand from the corresponding author. of anonymity and confidentiality. Fifth, the data were collected after only 1 month of the lockdown, and Declarations the expectation is that the rate of violence will escal- Ethics approval and consent to participate ate with prolonged lockdown and school closure. Fi- This study was approved by the institutional Research Ethics Committee, nally, the pattern of violence described cannot be Faculty of Medicine, Sohag University, on 1 April 2020 and was carried out in accordance with the principles of the 1964 Declaration of Helsinki and its attributed to COVID-19 in view of the absence of in- 2013 revision. Committee reference No.: not available. Informed consent of formation regarding the child disciplinary pattern participants was obtained from the respondents by submitting the consent prior to the pandemic. statement included in the online survey. AboKresha et al. Journal of the Egyptian Public Health Association (2021) 96:11 Page 10 of 10 Consent for publication against children. 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Fabbri C, Bhatia A, Petzold M, Jugder M, Guedes A, Cappa C, et al. Modelling the effect of the COVID-19 pandemic on violent discipline

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